Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0296, written 3 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jun 2024 |
|---|---|
| Reference | 2024-0296 |
| Deceased | Tcherno Bari |
| Coroner | James Bennett |
| Coroner area | Birmingham and Solihull |
| Category | Suicide (from 2015) |
| Organisation named | Birmingham and Solihull Mental Health NHS Foundation Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | 9 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: (1) , Chief Executive, Birmingham and Solihull Mental Health NHS Foundation Trust (‘BSMHFT’) (2) (3) Parties to the National Partnership Agreement: Right Care, Right Person: , Chief Constable, West Midlands Police (‘WMP’) a. Department for Health b. Home Office c. College of Policing: d. NHS England: e. National Police Chiefs’ Council: f. Association of Police and Crime Commissioners: , Chief Executive Officer , Chair , Chief Constable , Chief Executive 1 2 3 4 CORONER I am James Bennett Area Coroner for Birmingham and Solihull. CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. INVESTIGATION and INQUEST On 05/10/23 I commenced an investigation into the death of Tcherno Bari. The investigation concluded at the end of the inquest on 21/05/24. CIRCUMSTANCES OF THE DEATH On 18/09/23 Mr Bari was sectioned under the Mental Health Act 1983 and admitted to a psychiatric unit at George Ward, Highcroft Hospital. He was diagnosed with psychotic depression. Mr Bari’s suicide risk factors included: (1) recent suicide attempts and ideation command delusions (being controlled by a chip in his head) and hallucinations (hearing two different voices making derogatory comments), (4) severe depression, and (5) cessation of anti-psychotic and anti-depressant medication (as recent as 24/09 and 25/09). , (2) recent breakdown of relationship, (3) paranoid On 25/09/23 he violently (which was a further suicide risk factor in that it amounted to a change in behavior) forced his way through two secure doors and left the grounds. The Responsible Clinician (a senior Consultant Psychiatrist) prescribed an urgent intravenous tranquillizer, but nurses were not in a position to restrain Mr Bari. The Responsible Clinician was of the view Mr Bari was presenting with psychotic depression with florid command hallucinations and active paranoid delusions and considered him to be at high-risk of suicide. The police were called promptly and searched the local area for around 1 ½ hours. He was found deceased 23 hours later, on the next day 26/09, hanging from a tree in parkland outside the police search area. The Nurse-in-Charge reported (relying only on her memory) some, but not all, of his suicidal risk factors during the 999 call. The call taker did not fully record this detail on the control log and the attending Constable was unaware. The Nurse-in-Charge (relying only on her memory) did not repeat this detail to the attending Constable and did not complete ‘appendix C – risk rating’ or hand it to the Constable (as required by the BSMHFT Missing Patient Policy) which would have amplified some, but not all, of his suicide risk factors. There was a conflict between the Nurse-in-Charge (an experienced and senior mental health nurse) and the police Constable (who was relatively inexperienced). The Nurse-in-Charge indicated Mr Bari was at high-risk of suicide. The Constable felt the Nurse-in-Charge could not rationalise the high-risk category, and decided Tcherno was at medium-risk of suicide (having in her view followed College of Policing: Missing Person Authorised Professional Practice). The medium-risk category was accepted by the Sergeant and Inspector, and later accepted by WMP’s Locate team, taking the Constable’s report about the facts at face value. The fact the police had taken a different view about the level of risk was not explained to George Ward, and neither the Nurse-in- Charge, Responsible Clinician, or Clinical Service Manager were aware. The Clinical Service Manager (as required by the BSMHFT Missing Patient Policy) did not ‘immediately’ (or at all) coordinate the attempts to locate the high-risk missing patient or invite a representative from WMP to a ‘daily appraisal’ meeting to discuss the information and circumstances. By the time Mr Bari was found deceased WMP had not requested BSMHFT’s written risk assessment which would have amplified some, but not all, of his suicide risk factors. CORONER’S CONCERNS During the inquest, the evidence revealed matters causing concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. My principal concern is that when a high-risk mental health patient is missing it requires effective and meaningful multi-agency co-ordination. Locally, it engages BSMHFT’s Missing Patient Policy (which purports to append WMP’s missing person procedures), national College of Policing: Missing Person Authorised Professional Practice (‘APP’), and National Partnership Agreement: Right Care, Right Person (‘RCRP’). The evidence revealed significant gaps in knowledge, co-ordination and application of these policies. Specifically: (1) I am not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. I am not reassured WMP officers are aware they should be provided with ‘appendix C – risk rating’. Context: I did not accept the Nurse-in- Charge routinely used ‘appendix C – risk rating’, and police witnesses - including a Locate Sergeant, and the Head of Locate, a Detective Chief Inspector - indicated they had never seen ‘appendix C – risk rating’. 5 (2) A ‘monitoring tool’ in the BMSHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’. Context: I was told this is under review, however I was concerned this is still outstanding 9 months following the death. (3) I am not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. I am not reassured WMP officers are aware this is the CSM’s role and of the expectation of being invited to a ‘daily appraisal’. Context: this process did not happen in Mr Bari’s case, and the WMP’s Head of Locate said she was not aware of the police ever being invited by a CSM to attend a ‘daily appraisal’. (4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. Context: I was told by WMP’s Head of Locate there has been an agreed ‘challenge’ process to WMP’s decision on risk category since February 2024, albeit BSMHFT have never used it. However, I heard from BSMHFT’s Head of Acute Nursing that there was no such process. Further, she explained ongoing frustration bearing in mind BSMHFT’s expertise, that WMP often do not accept BSMHFT’s reported high-risk category, WMP often do not communicate they have not accepted it with BSMHFT only finding out much later, and WMP often close missing patient investigations without informing BSMHFT. (5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP. I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date. (6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category. BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information. (7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment, or require attending constables, or later the Locate team, to request a copy of the risk assessment. In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category. (8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person. Context: police witnesses agreed that BSMHFT clinicians were the experts on mental health diagnosis, including identifying those conditions that carry an increased risk of suicide, and assessing the risk of suicide generally. However, this case demonstrates how in the heat of the moment an (inexperienced) attending constable can overlook that expertise and quickly dismiss it. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. BSMHFT and WMP are responsible at a local level for their own missing person/patient policies and the local implementation of RCRP and APP. 6 College of Policing is responsible for APP (and a party to the national RCRP agreement). The remaining recipients are all parties to the national RCPR agreement. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 July 2024. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: 7 8 (1) Mr Bari’s family. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Signature: 9 James Bennett Area Coroner, Birmingham and Solihull 03/06/24
9 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr James Bennett Birmingham and Solihull Area Coroner Coroner's Court, Steelhouse Lane, Birmingham, B4 6BJ Sent by email: Dear Mr Bennett, 2nd September 2024 RE: Prevention of Future Deaths Report dated 03/06/2024 relating to the death of Tcherno Bari. Thank you for sharing the Regulation 28 Report relating to the tragic death of Tcherno Bari on 26/09/2023. On behalf of the Association of Police and Crime Commissioners (APCC), I would like to express my deepest condolences to Mr Bari’s family for their loss. Given the references to national organisations within your report, it may be helpful for me to provide some background on the role of the APCC and to emphasise the non-operational role our members fulfil in their local policing areas. The APCC is the national membership body that supports Police and Crime Commissioners (PCCs), Police, Fire and Crime Commissioners (PFCCs), Deputy Mayors and other local policing bodies in England and Wales to provide national leadership and drive strategic change across the policing, criminal justice, and wider community safety landscape, to keep communities safe. This role is partly evidenced by our decision, based on member feedback, to co-sign the National Partnership Agreement in July 2023, an agreement that supports the roll out of the Right Care, Right Person approach. As a membership body, the APCC cannot mandate actions upon its members. However, our role does include the provision of advice and recommendations to inform our members’ local activities, including the development of evidence-based guidance. At a local policing level, PCCs are not responsible for making operational policing decisions, including the implementation of Right Care, Right Person, this is a decision for Chief Constables. Rather, PCCs are responsible for scrutinising their Chief Constables and holding them to account for the delivery of their duties. Additionally, PCCs have responsibilities to commission services, and where necessary, to bring partners together and work with them. To reflect these key responsibilities, the APCC has developed guidance for members on the Right Care, Right Person approach. The guidance, which was launched in April 2024, strongly encourages PCC oversight of the planning and delivery of the Right Care, Right Person approach to ensure vulnerable people receive the right support from the right services. The APCC guidance also advocates for PCCs to work closely with partners, including health and local authorities to develop robust implementation plans, and forums to discuss issues as they arise and to agree appropriate solutions. A copy of this guidance, which we keep under review with input from national health and policing partners, is available to read here - https://www.apccs.police.uk/media/9608/apcc-guidance-right-care-right-person-april- 2024.pdf#/media/media/edit/31855 With regard to operational learning arising from this Prevention of Future Deaths Report, we understand colleagues from the National Police Chiefs’ Council are reviewing your correspondence to identify relevant national learning. The APCC meets regularly with these colleagues and will seek assurances that where appropriate any identified learning is shared with local areas. We also understand that West Midlands Police is closely considering the report in line with their operational activities to identify learning. We hope this provides you with reassurance that the APCC and its members are prioritising effective scrutiny and oversight of the Right Care, Right Person approach, and we remain open to receiving important learning to keep local communities safe and support vulnerable people. Yours sincerely, APCC Chief Executive
Legal Department Uffculme Centre 52 Queensbridge Road Moseley Birmingham B13 8QY Mr James Bennett, Area Coroner, Birmingham and Solihull Areas, BIRMINGHAM B4 6BJ BY EMAIL ONLY TO: Our Ref: Your Ref: Date: 26 July 2024 Dear Mr Bennett, Re: Prevention of Future deaths Tcherno Bari Thank you for your Prevention of Future Death (PFD) report dated 3 June 2024, which I understand has also been sent to other parties for their response. I would like to begin by offering my sincere condolences to Mr Bari’s family. Please accept my assurances that as a Trust, we have learned lessons from the information which came out of the inquest and we will continue to work together with West Midlands Police and other agencies going forward to ensure that patients receive the best possible care. I will address each of the points that you have raised in turn. Some points West Midlands Police may be able to provide more detailed information than BSMHFT. 1) You were not reassured BSMHFT staff are handing attending police officers ‘appendix C – risk rating’ as required by their missing person policy. At the time of the inquest the Missing Persons Policy was being upated, in line with changes from Right Care Right Person (RCRP). Since this time the update has been completed and there have been a number of changes made. In addition the Trust have a new Executive Director of Quality and Safety/Chief Nursing officer who will be accountable for the policy. The updated policy has included valued feedback from the inquest. I can inform you that the appendix C risk rating form that you saw at the inquest has been stepped down, due to emerging evidence in the area. The new version of Appendix C form is a decision recording form which also includes a section which sets out ‘why the risk is considered to be present’. The form will be read out to the police in the recorded phone call and it will also be handed over to the police when they attend. I enclose a copy of the updated policy which I hope will provide you with reassurance of the progress made from the old policy. Customer Relations: Mon–Fri, 8am–6pm │ │ Website: www.bsmhft.nhs.uk 2) A ‘monitoring tool’ in the BMSHFT Missing Patient Policy requires routine monitoring to ensure nurses are completing ‘appendix A’ and ‘appendix B’, but not ‘appendix C – risk rating’. The updated policy, which has now been approved by both the Trust and our colleagues in the West Midlands Police has an updated Audit and Monitoring tool which requires quarterly and annual audits to be presented to the clinical governance committee for assurance, lead by the Matron for each inpatient area. Whilst this previously did not include Appendix C, it has now been updated to include this. 3) You were not reassured BSMHFT Clinical Service Managers (‘CSMs’) are (a) coordinating the attempts to locate high-risk missing patients, and (b) inviting a representative from WMP to attend ‘daily appraisal’ meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. On 25 June 2024 there was a training session put together which was attended by Clinical Service Managers, Nurse Managers, Matrons, Ward Managers for the in-patient wards and the Home Treatment Team Managers. During the session this inquest was used as a training tool and staff were reminded of their professional responsilibties, particularly around the co-ordination with police and daily meetings. Flash cards were provided to ensure that CSM’s are reminded of what they should be doing when patients go missing. Since the inquest, when incidents of patient’s going missing have occurred the correct processes have been followed. Reflection is being prepared for the most recent case and will be shared with the areas to ensure lesson learning is being shared. 4) I am not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. The updated policy sets out clearly the RCRP escalation process (challenge process) under Appendix K. This has been circulated to responsible clinicians and senior nurses within BSMHFT. As the escalation procedure contact details alter in the future, the process will continue to be updated and circulated to all senior clinicians in BSMHFT and will continue to be part of the missing persons policy. The Trust Updated missing person policy also now states explicitly that there is a expectation that the police recognise the expertise of BSMHFT clinicians in identifying missing persons with critical concern in the mentally ill. There is an expectation that this is respected by the police. Any disagreements are handled via the escalation process at a senior level. As I explained earlier this Policy was developed in conjunction with West Midlands Police.. The new policy has now been approved on 2 July and in addition to this being circulated to all clnical staff, training on the Policy will also be in place in the next 6 weeks. The training will target two key areas; there will be online training for staff to watch and also flash cards and posters in clinical areas which will flag the key points staff needed to remember to do in the cases of patients going missing. There will also be promotion on the Trust intranet for staff to alert them to the new policy and the training materials. 5) The BSMHFT Missing Person Policy purports to append WMP’s missing person process but makes no mention of RCRP. I am not reassured the BSMHFT Missing Person Policy is therefore accurate and up-to-date. As identified earlier in our letter, at the time of the inquest the Missing Persons Policy had not yet been finalised following the introduction of RCRP. The National Chief Police Offcers Council and National College of Policing have issued guidance in line with RCRP. RCRP National partnership agreement has been signed by the Department of health and Social care and the Home office. Following this the trust has comprehensively updated its missing person policy in line with the National guidance and partnership agreement on RCRP. The policy is attached for your reassurance. 2 6) RCRP does not require WMP to formally indicate to BSMHFT (i.e. via a form) when the police have taken a different view about the risk category. BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information. Under the updated policy the police will formally notify BSMHFT in writing, with their decision and reasoning if they have decided not to deploy immediately, when critical concern is communicated to them by a mental health nurse in regard to a inpatient who is missing. This would enable the escalation process to be taken forward by senior clinicians as set out in Appendix K, if necessary. 7) The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment, or require attending constables, or later the Locate team, to request a copy of the risk assessment. In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category. The fundamental expertise of BSMHFT clinicians in assessing critical concern in the mentally ill is crucial for the police to recognise. Appendix C has been now been developed into a document which sets out the reasoning for critical concern for the missing person by BSMHFT clincians. Sharing this will assist the police in understanding the rationale for why a clinician may consider a patient to be high risk . The escalation process also enables a more detailed discussion at a senior level between BSMHFT and the Police to assess and convey critical concern and share the basis for reaching such a conclusion. 8) RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. This is a point which the Trust would not be able to respond to as this is for West Midlands Police. We will therefore let them provide you with their response to this point. Yours sincerely Chief Executive BSMHFT 3
James Bennett Area Coroner – Birmingham and Solihull Coroner’s Court Steelhouse Lane Birmingham B4 6BJ 13 September 2024 Dear Mr Bennett, Preventing Future Deaths Report – Tcherno BARI. Thank you for providing the College of Policing with a copy of your report dated 3 June 2024 following the death of Tcherno Bari. I understand a number of concerns have been raised specifically in relation to the communication and risk assessments between West Midlands Police (WMP) and Birmingham and Solihull Mental Health Foundation Trust (BSMHFT), with the College being cited as the organisation responsible for Approved professional Practice (APP) and party to the Right Care Right Person (RCRP) national initiative. The College of Policing work closely with the National Police Chiefs’ Council (NPCC) who have established a national Right Care Right Person (RCRP) team to support forces by providing advice and guidance in their development and implementation of RCRP. The College of Policing have worked with the NPCC to publish a guidance toolkit; Right Care Right Person toolkit | College of Policing The toolkit was developed with the NPCC along with national partners and sets out that Right Care Right Person aims to ensure vulnerable people get the right support from the right emergency services. It applies to calls for service about: • concern for the welfare of a person • people who have walked out of a healthcare setting • people who are absent without leave (AWOL) from mental health services • medical incidents The toolkit was fully published by December 2023 and forces have been encouraged to follow the guidance within their development of RCRP. The RCRP toolkit applies specifically to the areas as set out above and does not encompass incidents relating to missing persons. However, it is acknowledged that some incidents which are at first treated as an RCRP related incident, including AWOL, may then turn into a missing person investigation. The Toolkit specifically raises this point to ensure forces provide clarity to their staff on which policy to follow when dealing with changing incidents. The toolkit states: It is important to distinguish between someone who is AWOL and someone who is missing (as defined by force policy). Within the College’s Mental health APP, under the section titled ‘AWOL patients’ see link: AWOL patients | College of Policing the professional practice sets out the following; • Police forces should consider including the following matters in their locally agreed multi-agency protocol for AWOL patients:… Response and communication strategies so that partner agencies understand what police actions and resources will be deployed as a result of reporting someone absent. The Missing Persons APP Missing persons | College of Policing is a separate and distinct policy that is not covered by RCRP, and sets out guidance to forces including the following; • By working together, sharing information and having a common understanding of processes, police forces and partner agencies involved with health, social care and safeguarding are able to support the proper management of missing person cases. • Senior officers should ensure that protocols are in place to support any situation where individuals are looked after, and should set out each organisation’s responsibilities and processes in relation to someone being absent or going missing. Collaborative development and implementation of protocols may also facilitate better relationships between agencies. o The protocols should include… an agreed inter-agency framework for classifying the degree of risk when an individual goes missing. • It may also be appropriate to involve other agencies, social services and health and mental health care professionals within the risk assessment process, particularly in relation to children in the care of the local authority. • The officer’s assessment of risk should be checked, verified and recorded on the appropriate form (*by a supervisor). • Mental health services should be consulted if a person is thought to be suicidal or suffering from a mental health crisis to find out if the person is known to them. • The hospital has a duty to ensure the welfare of the individual, and should be expected to undertake reasonable enquiries… Where there is immediate risk of harm, police should not delay action to find the missing person. The College has been working with the NPCC to ensure that the Missing Persons APP is as clear as possible in relation to communication between police and mental health services. We continually keep under review any amendments required including the need to update the language used in the APP to include a stronger emphasis on consulting mental health services. The College is also currently undertaking a full review of the Mental Health APP, and the points raised in regard to officers having regard to the expertise of mental health clinicians will be included within this review process. I understand that West Midlands Police are working with partners on the implementation of RCRP and are currently in the process of reviewing their policies and procedures in line with the College of Policing toolkit and Approved Professional Practices. I hope this is useful and that it helps to reassure you that our APP and Toolkit guidance, along with the scope of our current review of the Mental Health APP, deals with the issues that you have highlighted. If there is anything further that we can assist with, please do not hesitate to contact me. Yours sincerely Chief Executive Officer College of Policing E:
Parliamentary Under Secretary of State For Patient Safety, Women’s Health and Mental Health. 39 Victoria Street London SW1H 0EU 6 September 2024 Our Ref: James Bennett Area Coroner, Birmingham and Solihull Steelhouse Lane, Birmingham, B4 6BJ By Email: Dear Mr Bennett, Thank you for your Regulation 28 report to prevent future deaths dated 3 June 2024 about the death of Tcherno Bari. I am replying as the Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of the death of Tcherno Bari and I offer my sincere condolences to his family and loved ones. I am grateful to you for bringing these matters to my attention. Your report raises concerns about missing persons policy and Right Care, Right Person (RCRP), and I note that you have directed your report to the Department of Health and Social Care (DHSC) as a party to the National Partnership Agreement (NPA) on RCRP. I also note that you have raised concerns with other relevant partners, including representatives from Birmingham and Solihull Mental Health NHS Foundation Trust, West Midlands Police and NHS England. Given the operational independence of police forces and the autonomy of clinical decision making, those partners are best placed to respond to some of the concerns you raise. DHSC does have a role in setting guidance and direction to the mental health sector and I will respond on these points in particular. I understand that the NPA, signed by the previous government, set out a collective agreement from DHSC, Home Office, policing, and NHS England to implement the principles of RCRP to end the inappropriate involvement of policing in mental health matters. The NPA did not set out a timeframe for areas to implement RCRP, instead stressing the importance of local partners working collaboratively to plan implementation to ensure that patient safety is maintained. The NPA stated that 'it is crucial that at the heart of planning and implementing RCRP for people with mental health needs, there is a focus on ensuring patient safety is maintained and people in mental health crisis are not left without support.' It also emphasised that the NPA and RCRP are 'not statutory and do not seek to override legislation, regulations, or statutory guidance that the police or health and social care partners are subject to.' Local policies should always be developed in accordance with the obligations set out in the Mental Health Act Code of Practice. The Code of Practice is clear on processes for missing persons. For example, Section 28.15 of the MHA Code of Practice sets out that 'the police should always be informed immediately if a patient is missing who is considered to be particularly vulnerable'. Moreover, Section 28.11 requires that "Hospital managers should ensure that there is a clear written policy about the action to be taken when a detained patient, or a patient on a CTO, goes missing. All relevant staff should be familiar with this policy. Hospital managers should agree their policy with other agencies – such as the police and ambulance services – as necessary." It is my understanding that RCRP had not been implemented in the West Midlands area at the time of Mr Bari's tragic death. I would expect that local partners will take the opportunity to reassess their joint processes on risk assessment, communication and escalation in light of your recommendations. I also understand that NHS England runs a working group with colleagues across the regions to ensure that learnings and insights are shared nationally. It is crucial that policing and health partners work closely together to provide an effective and timely response to vulnerable people with acute mental health needs. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely,
Mr James Bennett
Area Coroner for Birmingham and Solihull
The Birmingham
and Solihull Coroner’s Court
Steelhouse Lane
Birmingham
B4 6BJ
National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
12 July 2024
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Tcherno Bari who died on
26 September 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 3 June
2024 concerning the death of Tcherno Bari on 26 September 2023, sent to the Chair
of NHS England. I am responding on behalf of the organisation in my capacity as
National Medical Director but would like to assure you that the Chair has also been
sighted on this response and has reviewed your Report. In advance of responding to
the specific concerns raised in your Report, I would like to express my deep
condolences to Tcherno’s family and loved ones. NHS England are keen to assure the
family and the Coroner that the concerns raised about Tcherno’s care have been
listened to and reflected upon.
Your Report raises concerns over gaps in knowledge and the coordination and
application of the local policies in place, and in use by Birmingham and Solihull Mental
Health NHS Foundation Trust (BSMHFT) and West Midlands Police (WMP), for high-
risk mental health patients that go missing, requiring effective and meaningful multi-
agency coordination. I note that you have directed your Report to NHS England as a
party to the National Partnership Agreement: Right Care, Right Person (RCRP) and
our response to you focuses only on the areas of concern that come under our remit.
The National Partnership Agreement: Right Care, Right Person (RCRP), which was
published in July 2023 and which NHS England is a signatory to, sets out a collective
national commitment to work to end the inappropriate involvement of police in
responding to incidents involving people with mental health needs. The RCRP outlines
key principles for implementation, including that a strong multi-agency governance
structure is needed to plan and develop the approach to delivery locally, so that patient
safety is not compromised and people are not left without the support they need. The
RCRP also states that local partners should work together to monitor and review
progress with implementation and set up local escalation processes to support multi-
agency partners to resolve challenges with rollout.
To support implementation, NHS England has shared information with health systems
about setting up multi-agency governance and delivery structures to oversee delivery,
manage risks and escalations and enable open communication between local
partners, including to resolve any challenges. Information has also been shared on
escalation protocols, including the need for local partners to set up real-time escalation
processes (in response to a situation that is currently live) and retrospective escalation
processes (to review situations that have occurred, learn lessons and agree changes
going forward). This information will be included in guidance that NHS England will
issue to health systems shortly.
NHS England takes all reports of actions that have not followed the principles of RCRP
seriously. A national oversight group has been set up, involving members from all
organisations that signed the RCRP, as well as representatives from wider health,
children and adult’s social care, police and voluntary, community, faith and social
enterprise (VCFSE) sector organisations. The purpose of this group is to review any
concerns and issues with RCRP that have been escalated nationally, to identify any
action required by national partners in relation to concerns and issues raised. This
oversight group feeds into a regular ministerial working group set-up to oversee RCRP
roll-out.
It is appropriate that BSMHFT and WMP respond to many of the concerns raised in
your Report. My Midlands colleagues have shared your Report with the Chief Medical
Officer for Birmingham and Solihull Integrated Care Board, as the commissioner of
services from BSMHFT, to ensure that they seek assurance from both BSMHFT and
WMP that the concerns in your Report have been addressed.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events are shared across the NHS at
both a national and regional level, and helps us to pay close attention to any emerging
trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
National Medical Director
Date: 25th July 2024 Dear Mr Bennett, RE: Regulation 28 Report to prevent future deaths – Tcherno BARI. I write to you in response to your Regulation 28 Report to prevent future deaths notice where you express concerns relating to this case referencing Missing person APP and Right Care Right Person (RCRP) National Partnership Agreement (NPA). Firstly, we would like to express our sincere condolences to the Family and friends of Tcherno, in what must be a very difficult time. By way of an introduction, it may be useful to provide you with a summary of what Right Care Right Person is and sets out to achieve, likewise in relation to the National Partnership agreement. It is also worthy of note that the first phase of the NPCC/College of Policing RCRP guidance was not published until July 2023 (alongside the NPA) which included the Senior responsible officer SRO role, Baseline and evaluation criteria and communication plan considerations modules. The policy considerations, force control room implementation and e-learning modules were published in December 2023. This was followed by the Implementation principles for incidents involving children in June 2024. It is our understanding that West Midlands Police are currently reviewing their policies and procedures against the Right Care Right Person national guidance. Right Care Right Person Right Care Right Person aims to ensure vulnerable people get the right support from the right emergency services at first point of call. It applies to calls for service about: concern for the welfare of a person • • people who have walked out of a healthcare setting • people who are absent without leave (AWOL) from mental health services • medical incidents The RCRP toolkit has been developed to support forces in England and Wales to: • decide the appropriateness of a police response to these calls • implement RCRP successfully and consistently, in partnership with health and social care agencies As outlined within the toolkit, Walk out of healthcare and Absent Without Leave (AWOL) are two separate and distinct policy areas, and information is provided along with relevant signposting to the appropriate section within the College of Policing APP. Information within the toolkit relating to AWOL and the distinction between missing persons can be found here. The Missing persons framework is another distinct policy area which falls outside of RCRP when it is established that a persons whereabouts cannot be ascertained and all reasonable enquires have been made by the informant to ascertain their whereabouts. The National Partnership Agreement (RCRP) In summary The National Partnership Agreement sets out a collective national commitment from the Home Office, Department of Health & Social Care, the National Police Chiefs’ Council, Association of Police and Crime Commissioners, and NHS England to work to end the inappropriate and avoidable involvement of police in responding to incidents involving people with mental health needs. Although the approach can be applied more broadly than cases relating to mental health, this document is focused on the interface between policing and mental health services, as one step towards implementing RCRP. Having reviewed your concerns in depth, it appears that the situation concerning Mr Bari was treated as a missing person from the outset by West Midlands Police, and therefore RCRP principles would not apply in any case, as it was assessed that there was an immediate risk to life/serious harm in which it would be appropriate for the police to respond (Article 2/3 European Court of Human Rights Act). We hope that the information we have provided has clarified the work undertaken within the National Partnership Agreement and the RCRP process. If you have any further questions please do not hesitate to contact us through the RCRP Project Manager Yours sincerely NPCC Right Care Right Person Lead
Keeping our Communities Safe and Reassured Working in partnership, making communities safer STAFFORDSHIRE AND WEST MIDLANDS POLICE JOINT LEGAL SERVICES Director of Legal Services Your Ref: Our Ref: Email: Date: 15 July, 2024 Dear Mr Bennett, Prevention of Future Deaths report dated 3 June 2024 I am the West Midlands Police (WMP) lead for the introduction of the National Partnership Agreement: Right Care Right Person (RCRP). I write in response to the Prevention of Future Deaths report dated the 3 June 2024 which followed on from the inquest touching upon the death of Mr Tcherno Braima Bari. The report identified eight key areas of concern to be addressed. 1. The provision of the ‘Appendix C- risk rating’ by Birmingham and Solihull Mental Health Foundation Trust (BSMHFT) staff to officers and the awareness of WMP officers that this should be provided. 2. A monitoring tool within BSMHFT Missing Patient Policy requires review of the completion of Appendices A and B but not Appendix C. 3. BSMHFT Clinical Service Managers (‘CSM’) are not a) co-ordinating attempts to locate high risk missing patients and, b) inviting a representative from WMP to attend daily appraisal meetings to discuss the high-risk missing patient’s absence as required by their missing patient policy. You were not reassured that WMP are aware this is the CSM’s role or of the expectation of being invited to a ‘daily appraisal’ meeting. 4. You were not reassured the RCRP ‘challenge’ process has been effectively communicated to BSMHFT. 5. BSMHFT Missing Patient Policy purports to append the WMP missing person process but makes no mention of RCRP. You were not reassured the BSMHFT Missing Patient Policy is, therefore, up to date. 6. RCRP does not require WMP to formally indicate to BSMHFT (via a form) when the police have taken a different view about the risk category. BSMHFT will often be unaware of the different view taken by the police rendering the ‘challenge’ process redundant and reducing the chances of the police identifying they have overlooked key information. 7. The BSMHFT Missing Patient Policy and RCRP do not require BSMHFT to hand attending constables a copy of the risk assessment, or require attending constables, or later the Locate team, to request a copy of the risk assessment. In the event of a conflict about risk category, requiring attending constables to take early possession of the written risk assessment may lead to the police identifying they have overlooked key information and revisit their own risk category. 8. RCRP and APP do not require attending constables to have particular regard to the expertise of mental health clinicians and hesitate or be extra vigilant before rejecting their opinion on risk category. RCRP and APP appear to regard reports from mental health clinicians no differently to those from members of the public, and family and friends of the missing person. This letter is the response on behalf of the Chief Constable of West Midlands Police. Given the issues identified within the report, in preparing this response West Midlands Police has liaised with the NPCC lead on Right Care Right Person, Chief Inspector Wayne Nash. I understand the NPCC will provide a response under separate cover. Right Care Right Person (RCRP) Since Mr Bari’s death there have been a number of developments within WMP in relation to RCRP. RCRP was published on 26 July 2023 and has been signed by: The Minister of State for Crime, Policing and Fire; The Parliamentary Under Secretary of State for Mental Health and Women’s Health Strategy; The Mental Health Lead of the National Police Chiefs’ Council; The National Mental Health Director at NHS England; The Mental Health Lead of the Association of Police and Crime Commissioners; and The CEO of the College of Policing. RCRP is an operational model which was initially developed by Humberside Police in relation to how emergency services respond to calls involving concerns about mental health. It is focused on the interface between policing and mental health services, although there is an acceptance that the principles can be applied more broadly. RCRP is in the process of being rolled out across the UK as part of ongoing work between police forces (including WMP), health providers and the Government. RCRP is designed to ensure that people of all ages, who have health and/or social care needs, are attended to by the right person, with the right skills, training, and experience to best meet their needs. RCRP seeks to alleviate the police being the default first responder as has been the case in most areas. RCRP has been shown to improve outcomes, reduce demand on all services, and make sure the right care is being delivered by the right person. The RCRP model has four phases. i) Phase 1 relates to ‘concern for welfare’ calls; ii) Phase 2 focusses on ‘AWOL’ and ‘walk out of health care facilities’; iii) Phases 3 deals with transportation of patients; and iv) Phase 4 concerns the use of powers under sections.136 & 135 of the Mental Health Act 1983 (MHA 1983) and voluntary mental health patients. The first two phases went live from 5 February 2024 for all partners collaborating within the West Midlands Region, including: WMP, Mental Health Trusts, Acute Trusts, Local Authorities, Integrated Care Boards, West Midlands Ambulance Service (WMAS) and West Midlands Fire Service. Phases 3 and 4 will be implemented in the Autumn of 2024. RCRP has been identified as the best practice, leading to national agreement and work to implement the policy. It was recognised that the lines had become blurred between partner agencies over many years resulting in untrained, and therefore inappropriate, resources attending incidents. Specifically, in relation to policing, this has led to adverse decisions in many cases. The aspiration of the partners collaborating to deliver RCRP in the West Midlands is to ensure that public service is delivered in the way that the agreement intended, such that members of the public get the support they need from appropriately trained individuals. Additional training has been provided to WMP Force Contact Call Handlers to ensure that the right deployment decisions are made when calls are received from members of the public or partners. This includes consideration as to whether the call relates to an Article 2 (immediate risk to life) or Article 3 (immediate threat of serious harm) issue, and where these are present to deploy a police resource only where there is a clear policing role. If there is a medical need only, with no policing role, even where Article 2 and/or Article 3 issues apply, then WMAS or mental health services may be the most appropriate agency to attend without police. A decision tree has been designed to support the correct application of the RCRP policy by call takers. A national training package developed by the College of Policing covering RCRP has been made mandatory for front line officers who are likely to be dispatched to these types of calls to ensure that they also understand the decision-making process. This package was deemed mandatory in the spring of 2024 and the current completion rate of those colleagues required to do so sits at 90%. A. Escalation HM Coroner was made aware of an escalation process that has also been put in place for our partner agencies during the inquest, should partners be concerned that a WMP colleague has not made the correct decision. The telephone number for contacting the most senior WMP officer on duty in the Force Contact Department has been shared (see Exhibit 1 below). This number allows partners to speak to the WMP Force Duty Manager directly, who will immediately seek a review of the decisions made. I am aware that the issue of escalation was discussed during the inquest and colleagues from BSMHFT were not aware of this process. I have since contacted the strategic lead for BSMHFT who is part of the Partnership Strategic Collaboration Board implemented to deliver the RCRP approach in the region. I was reassured that the escalation process had been circulated at go live in February 2024 and that it had also been recirculated as a result of this report. The escalation process was also discussed again at our most recent Strategic Collaboration Meeting in June 2024 with a reminder to all partners to ensure it was circulated widely amongst their organisations. B. Risk Assessment and Management The WMP Locate Team sits within the Public Protection Unit (PPU) and their role is to lead missing person investigations after the initial attendance of officers. Within the PPU there is an intervention and response team who engage with external stakeholders including mental health trusts. This team can escalate issues to the mental health trust for example in relation to a specific missing person investigation. As noted within the PFD report the BSMHFT policy provides for WMP to be invited to ‘daily appraisal’ meetings although this is not something WMP were aware of previously or routinely invited to attend. Should a request be made for WMP to attend a BSMHFT daily meeting for a high-risk missing person we would support BSMHFT and send an appropriate staff member, as required. The WMP missing persons policy will be updated to reflect this. The PFD Report also addresses the issue of difference between the WMP and BSMHFT risk categories. BSMHFT does not have access to WMP systems or to the COMPACT log which is used to record a missing person investigation so could not use this to formally indicate a difference in opinion. However, the WMP missing persons policy will be updated to remind all officers, when attending such calls to identify the mental health trust’s risk category and to recognise the importance of clinician’s expertise in determining the risk assessment. Officers will be reminded that they must consider risk from the stakeholder/partner perspective and obtain the rationale of the treating clinician where there is a difference. This should then be recorded on COMPACT and fed back to WMP supervisors and shared with the reporting partner agency. The WMP student training programme and input with regard to missing persons will also be updated to reflect the importance of this conversation, giving due weight to a clinician’s risk assessment and rationale and recording this so the challenge process can be enacted, if appropriate. WMP recognise the importance that the BSMHFT risk assessment is shared with officers (referred to as ‘Appendix C’ in the PFD report) and that attending constables know to request this. Whilst officers will be reminded, within the policy update, to request a copy of the risk assessment and to take possession of it they will also be given an email address to provide to BSMHFT. BSMHFT will be asked to provide the risk assessment (Appendix C) electronically to this email address. The risk assessment will be received into the central Locate Team inbox ensuring a hard copy document is not misplaced and enabling timely supervisory review, if required. The Locate Team inbox is only monitored until 10pm. Therefore, for overnight issues the Duty Sergeant will be asked to monitor the inbox and to escalate any issues through supervision where appropriate. The WMP missing person policy will also be updated to reflect the need to update the reporting authority or family member should a missing person investigation be closed. The WMP Missing Person Policy is distinct to the WMP RCRP policy, but it is recognised that they must compliment each other as some RCRP initial reports will become missing person enquiries. This is written into the RCRP person policy stating ‘This policy is to be read & exercised in line with any other relevant WMP Policy e.g. Missing Persons/Mental Health etc’ And ‘It is often the case that Concern For Welfare reports become missing person enquiries once initial actions have been completed. Cases involving missing persons are subject to specific policies which will be followed when taking the original call. Link to Missing Persons Policy.’ The process for updating the missing person policy, as referenced above, has commenced. However, given the changes this will require a full policy review. Therefore, it is likely to take 8 weeks from commencement to completion. A further update, together with the revised policy, will be provided to HM Coroner once completed. A Vulnerability Desk has also been created within Force Contact which operates in line with the RCRP policy allowing call handlers and operational colleagues the ability to escalate complex concerns to this team of subject matter experts consisting of Mental Health Tactical Advisors, Missing from Home experts and Supervisors. If WMP can be of further assistance in relation to this matter, please do not hesitate to contact me. Yours sincerely Chief Superintendent Right Care, Right Person Lead West Midlands Police EXHIBIT 1 Incident reportedIs there a real and immediate risk to life, or of significant harm occurring to an identified person or the public?Does the concern primarily relate to a medical, mental health or vulnerabilityissue?YESNONOYESIs the location of the person the concern is for known or reasonably suspected?YESNODoes the concern primarily relate to a medical, mental health or vulnerability issue?NOYESIs there an immediate and significant risk to a partner agency / public, or a clearly-defined police support role?YESNOHave reasonable attempts to locate the individual been made by partner agency / caller?YESNOPartner agency / caller to make enquiries. THRIVE and keep under continuous reviewTHRIVE and assess whether to treat as a missing person enquiryIs there a clearly-defined policing purpose? (e.g. report of crime)YESTHRIVE and deploy if appropriateTHRIVE and deploy if appropriateNONOYESIs the location of the person the concern is for known or reasonably suspected?THRIVE and deploy in support of the lead agencyTHRIVE and assess whether to treat as a missing person enquiryTHRIVE and lead agency to resolve without police intervention unless circumstances change Are there any other factors or additional information/intelligence that necessitate police intervention?YESTHRIVE and deploy if appropriateNOTHRIVE, provision of advice and finalisationAt this point you will have decided that the incident does notmeet the threshold for attendance. The caller should be informed:“This incident does notmeet the threshold for deployment and as a result the police will notbe attending”.If the caller is from a partner agency, advise them that they have primary responsibility for dealing with the incident. You may suggest appropriate alternative organisations they may wish to confer with, depending on the type of incident they are reporting(e.g. Fire Service / Highways Agency / Local Authority etc).If the caller is a private individual, consider signposting or notifying the most appropriate partner agency on their behalf, either at the time of the call or via the Forms App / ‘Go To Guide’, having first obtained consent from the caller. The following options are not exhaustive, but agencies could include:Medical: Ambulance / A&E / NHS 111 / GPMental Health: Crisis Team / CAMHS / Samaritans / GP / AmbulanceOther vulnerability: Child Services / Adult Social Services / Local Authority / Education Welfare / Housing ProviderAdvise the caller they should recontact police if there is a change in circumstances, so that any fresh information can be assessed.No deploymentAt this point you will have decided that the response to the incident shouldnot be police-led, yet it may be appropriate to offer conditional support to the lead agency, subject to defined criteria being met. The caller should be informed:“The primary responsibility for dealing with this incident rests with another agency, however police will provide support”.If the caller is from a partner agency, advise them that they have primary responsibility for dealing with the incident, but provide details of the circumstances under which police may provide proportionate support by performing a specified role that falls within police powers and policy. It is anticipated that police support would be most applicable in cases where a partner agency is on scene. (For example, where paramedics are outside an address to deal with a medical emergency but cannot gain entry and there is a realand immediate risk to life, police may assist by forcing entry under S17 PACE to grant them access to the patient).If the caller is a private individual, either signpost them to the appropriate agency and advise them of the circumstances under which police may be able to provide support, or if appropriate, make contact with the relevant agency at the time of the calltonotify them of the incident and offer conditional support in line with police powers and policy.Advise the caller they should recontact police if there is a change in circumstances, so that any fresh information can be assessed.Conditional deploymentRight Care, Right Person: Deployment Flowchart*Shared with strategic partner leads present on 24/1/24 as reassurance and not for distribution beyond those individual persons present without prior agreement from Chief Superintendent Kim MadillThe above process is not exhaustive and should be used as a template for guidance. The call handler should continuously assess all relevant information and apply the correct grading based on the risk identified. It is essential that checks of WMP systems are conducted to identify any other relevant information / intelligence to inform decision-making. Particular care should be given to incidents involving children and vulnerable people. In all cases, rationale for the decisions made should be documented, using THRIVE where appropriate. EXHIBIT 2 Right Care, Right Person Escalation Point of Contact for Partner Agencies to West Midlands Police If any partner has a concern that the RCRP policy and partnership agreement has been incorrectly applied in particular where they believe there is a Is there a real and immediate risk to life, or real and immediate risk of significant harm occurring to an identified person or the public this escalation process will apply 24/7 from 2200hrs on 9th February 2024. - Operational colleagues in the organisation with the concern should escalate the issue expeditiously through their own internal processes - If the senior manager then believes that this then needs immediate escalation to a senior West Midlands Police leader as the original decision does not align with the RCRP agreed approach they should call the Force Duty Manager on the below number 0844 589 6674 The Force Duty Managers are Chief Inspectors based in West Midlands Police Force Contact Centre. They are trained in RCRP and aware of this escalation process. Action to be taken On receipt of the call they will ensure the original decision is reviewed and where required appropriate action initiated. They will share the detail of the escalation with the below colleagues for further discussion with partners and to ensure that the nature of the incident is understood and any appropriate action take to prevent similar escalations SRO for RCRP SME for Mental Health – MH Coordinator –
DBE MP Minister of State for Policing, Fire and Crime Prevention 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 20 September 2024 Mr James Bennett Area Coroner, Birmingham and Solihull By email: DECS Reference: Dear Mr Bennett, Thank you for your correspondence enclosing a copy of the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Tcherno Bari, and for the extension of time to respond to you. I apologise for the delay in responding. I was saddened to learn about the death of Mr Bari, and I would first like to express my deepest condolences to his family for their loss. As you are aware, police forces are operationally independent and so it is for the National Police Chiefs’ Council, the College of Policing and West Midlands Police to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Bari, and I know they have written to you separately on this matter. It may help if I outline the rationale and purpose of the National Partnership Agreement (NPA), as the Home Office was one of the signatories when it was published in July 2023. The National Partnership Agreement was published following extensive engagement with partners, including from health and social care professional bodies, the College of Policing, the voluntary sector, and people with lived experience. The document sets out key principles of the policing approach called Right Care Right Person (RCRP) and its application to mental health-related incidents. The RCRP approach aims to reduce police time spent on mental health incidents and help ensure that the most appropriate agency attends, to provide the best possible service for those in need. Though the RCRP approach can be applied more broadly than cases relating to mental health, the National Partnership Agreement is focused on the interface between policing and mental health services, as one step towards implementing RCRP. As Policing is operationally independent, each Chief Constable has to decide whether and when to implement Right Care Right Person and how much of the framework set out in the National Partnership Agreement and supporting guidance they wish to adopt. The areas which Right Care Right Person covers are: concerns for welfare; responding to situations where voluntary patients leave acute and mental health healthcare facilities before treatment is complete; responding to cases where people are 'absent without leave' as set out in the Mental Health Act (1983); handovers between police and health following use of S136 of the Mental Health Act; and transportation of patients to or between healthcare facilities. Missing Persons is not a part of this and existing police procedure regarding police involvement should continue to operate. Thank you again for writing to me. We take the duty of care of vulnerable people seriously and continue to work to make improvements. Yours sincerely, Minister of State for Policing, Fire and Crime Prevention
Missing Patient Policy
Policy number and category
C37
Clinical
Version number and date
3
june 2024
Ratifying committee or
executive director
Clinical Governance Committee
Date ratified
July 2024
Next anticipated review
April 2025
Executive director
Executive Medical Director
Associate Medical director for Mental health
legislation
Policy lead
Policy author (if different from
above)
Exec Sign off Signature
(electronic)
Disclosable under Freedom
of Information Act 2000
Yes
Policy context
This document lists the actions to be taken when a patient is missing from a community or
inpatient setting or absent without leave (AWOL). This policy applies to all patients open to
Birmingham and Solihull Mental Health NHS Foundation Trust (BSMHFT).
The Policy needs to be implemented in the context of Right Care Right Person National
Framework, National Police Chief’s Framework Guidance and The National Multi-agency
Response for Adults Missing from Health and Care Settings Guidance for England.
A national framework for England
Policy requirement (see Section 2)
This policy replaces all previous Trust and Locality policies and procedures relating to
patients who are Missing / Absent Without Leave (AWOL).
The policy describes the actions to be taken when a patient is missing or AWOL
The actions required are described as they relate to Informal inpatients, Detained patients
who are AWOL and patients in the community.
The Policy needs to be read in line National Partnership Agreement: Right Care, Right
Person (RCRP)
1. Introduction
1.1
1.2
1.3
Rationale
Scope
Principles
2. The Policy
3 The procedure
3.1
Inpatients who are missing
3.1.1 Stage 1 – Detained or Informal Patient Missing or Unaccounted For
3.1.2 Stage 2 – Initial Search
3.1.3 Stage 3 – Determining the Category of Risk
3.1.4 Stage 4 – Notification
3.2
3.3
3.4
3.5
Detained Patient Absconding from Escorted Leave
Returning an AWOL Patient
Return of AWOL Patients
Time Limits
3.6 Missing Community Patients
3.7
Recording
4 Responsibilities
5 Development and Consultation process
6 Reference documents
7 Bibliography:
8 Glossary
Audit and assurance
9 MONITORING TOOL – MISSING PATIENT POLICY
10 Appendices
3
3
3
3
4
5
5
5
5
6
8
8
9
10
12
13
14
14
15
15
16
16
21
21
21
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1.
Introduction
1.1
Rationale
Birmingham & Solihull Mental Health NHS Foundation Trust (the Trust) has a duty to provide safe
and effective services for those who are receiving a service from the Trust. This document lists the
actions to be taken when a patient is missing from a community or inpatient setting or absent
without leave (AWOL).
1.2
Scope
This policy applies to all patients open to Birmingham and Solihull Mental Health NHS Foundation
Trust (BSMHFT). Patients open to the Trust who are detained under the mental health act, or liable
to be detained under the act, when missing are to be treated as being absent without leave
(AWOL)
All employees of BSMHFT and those working with the Trust as students or other training roles,
secondments or under contract, including agency workers.
A missing person is anyone whose whereabouts can’t be established and:
• The context suggests the person may be a victim of crime; or
• The person is at risk of harm to themselves or another; or
• Where there is particular concern because the circumstances are out of character, or there
are ongoing concerns for their safety because of a previous pattern of going missing.
1.3
Principles
• The safety of BSMHFT patients is of paramount concern.
• The Trust recognises the need to make clear the difference between AWOL and Missing
Patients and the differences in approaches to be taken between the two groups.
• The Trust has a legal obligation to correctly apply the MHA when a patient is AWOL.
• When a patient is missing or AWOL it is likely BSMHFT will need to involve our partners.
We will only ask for assistance from partners when it is necessary to do so.
• The patient will be immediately categorised as a missing person where there is critical
concern for the patient’s or public’s safety that justifies an immediate police response (i.e.,
an Article 2 or Article 3 duty, or there are suspicious circumstances that suggest the patient
may have been a victim of a serious crime);
•
• The patient will not be categorised as a missing person where there is no critical concern
for the patient’s or the public’s safety unless the BSMHFT has conducted reasonable
actions to locate the patient, including checking the patient’s home address, and the patient
is now considered to be missing from home, as well as missing from the medical facility.
If there is critical concern that justifies an immediate police response, the police would
normally record the patient as a missing person and conduct enquiries to locate the missing
patient.
If there is no critical concern that justifies an immediate police response as per the police.
BSMHFT has to conduct reasonable actions to locate the patient, including checking the
home address where possible and safe to do so (with police assistance where appropriate),
lack of action of one agency does not absolve another agency of its responsibilities to
protect life and prevent degrading treatment (suffering).
•
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• Where there is disagreement as to whether there is critical concern regarding the missing
patient between the reporting nurse and the Police.
• The Police should provide their reasoning for the decision in writing via email to the nurse.
The Nurse should seek the reasoning in writing via email if not readily provided.
• BSMHFT clinicians are the experts on mental health diagnosis, including identifying
those conditions that carry an increased risk of suicide, and assessing the risk of
suicide generally and their assessment of critical concern in this area should be
accepted by the Police. Should this not be accepted.
• This will be escalated to the senior most nurse in the Hospital (CNM, Duty senior
nurse) at that time and the RC (responsible clinician)/consultant psychiatrist . Who
will then follow the escalation procedure as set out in Appendix K.
• Predicting low frequency events such as suicide is not possible with Any degree of
accuracy based on a risk assessment tool. Events such as serious harm or death even in
the most severely mentally ill are low frequency events.
• Current NICE guidance (National Institute of Clinical Excellence)1 recommends that the
NHS.
• Do not use risk assessment tools and scales to predict future suicide or repetition of self-
harm.
• Do not use risk assessment tools and scales to determine who should and should not be
offered treatment or who should be discharged.
• Do not use global risk stratification into low, medium or high risk to predict future suicide or
repetition of self-harm.
• Do not use global risk stratification into low, medium or high risk to determine who should
be offered treatment or who should be discharged.
• Given the above Global Risk stratification as High, medium and Low should not be made to
make decisions.
If there are any significant doubts or disagreements over which category the patient should
be allocated, then the critical concern category should be used.
2. The Policy
• This policy replaces all previous Trust and Locality policies and procedures relating to
patients who are Missing / Absent Without Leave (AWOL).
• The policy describes the actions to be taken when a patient is missing or AWOL.
• The actions required are described as they relate to Informal inpatients, Detained patients
who are AWOL and patients in the community.
1 https://www.nice.org.uk/guidance/ng225
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3 The procedure
3.1 Inpatients who are missing
3.1.1 Stage 1 – Detained or Informal Patient Missing or Unaccounted For
Any member of staff, who becomes aware that a patient has gone absent without leave or is
otherwise unaccounted for, should immediately inform the nurse-in-charge of the patient’s ward.
Not all patients who leave a health facility without being formally discharged are missing people.
Many patients go home and consequently their whereabouts can be easily established. A missing
patient is not a missing person if they are at home and they are not considered high risk / of critical
concern.
The nurse-in-charge will ensure that the following procedures are undertaken whilst completion of
the first part of the Trust’s ‘Missing Patient Form 1’ is completed (Appendix A).
If it is certain that the missing patient is NOT on the ward, for example they have left the hospital
grounds or have not returned from leave, the nurse-in-charge will go directly to Stage 3 of this
procedure. Otherwise the nurse in-charge must implement Stage 2.
The nurse-in-charge should inform the patient’s Responsible Clinician (RC) immediately if they are
on duty or at the earliest opportunity when the RC returns to duty.
MHL office doesn’t need Missing Patient Form as they get the eclipse of AWOLS.
Patients who are detained in a Low, Medium or High secure hospital, must have their absence
reported to the Care Quality Commission (CQC)
Restricted patients must have their absence reported to the Ministry of Justice. When they return
from absence that too must be reported to MoJ. Reporting forms are in appendix G.
There is no automatic requirement to notify the victim when a restricted patient (see section 8 for
definition of restricted patient) or a Section 37 patient absconds, but the risk to any identified victim
should be considered and care planned in a section 17 leave process and via the MAPPA process.
In all events of a restricted patient being absence there should be an immediate consideration of
any victims. A discussion with the Responsible clinician or on-call Consultant must inform part of
that discussion.
3.1.2 Stage 2 – Initial Search
The objective of an initial search of the ward is to confirm that the patient is not within the confines
of the building in which the ward or unit is situated.
The nurse-in-charge must organise a thorough search of the ward and other areas within the
building, including any adjacent rooms, corridors, cupboards, pathways or roadways.
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If the patient is not located, the nurse-in-charge must then contact any other wards, departments or
services on the same campus or site and request that a similar, thorough search is undertaken
within those buildings.
If the patient is located outside of the ward and in the hospital grounds, staff should attempt to
persuade the patient to return.
In the case of a detained patient, if all attempts at persuasion fail to achieve a detained patient’s
return and there is enough staff present to safely affect a forced return, then force may be used
providing that it is ‘reasonable’. In these circumstances, ‘reasonable’ means the minimum force to
achieve the required outcome.
Where an informal patient leaves the ward and is located within the hospital grounds, or in close
proximity to the hospital the patient, if willing, should be persuaded to return.
If a voluntary patient has left the ward, and is found in the hospital grounds, but is unwilling to
return to the ward, then a nurse of the prescribed class (RMN / LD Nurse) should consider whether
there are grounds for the implementation of the nurse’s holding power under section 5(4) of the
Act. Section 5 (4) can only be used by a qualified mental health or learning disability nurse, who
cannot be instructed to use the power but must make a personal decision. It can only be used
when the patient is still on the Trust premises. The nurse using the power must be satisfied that the
patient is suffering from a mental disorder to a degree that it is necessary for their health or safety,
or the protection of others, that they are not allowed to leave the hospital.
If an informal patient is located outside of the hospital grounds and refuses to return, the return of
an informal patient to hospital against their will would require the police to use a Section 136 and
take them to a place of safety for a Mental Health Act. Police may only use this power while a
patient is outside of a domestic residence.
If the patient is not located after Stage 2 is completed, then the nurse-in-charge will proceed to
Stage 3 below.
3.1.3 Stage 3 – Determining the Category of Risk
For the purpose of determining whether to notify the police service within these procedures the
current Trust approved Risk Assessment document should be completed and documented within
the patient’s clinical record. The Decision-Making Tool in Appendix C should also be completed.
The following definitions may aid decision making:
Critical concern is the wording for the purpose of communicating with
the police.
The missing patient presents a risk to themselves or others. The patient may be subject to a
detention order under the Act, or they may be informal or voluntary.
Other factors that need to be considered include any potential victims or child protection issues.
Such a decision must be made jointly involving the nursing team on duty and the Clinical
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Service/Nurse Manager (CS/NM) or Lead Nurse (or on-call manager if out of hours) and a member
of the RC’s medical team or the on-call junior doctor, who may wish to consult the consultant on-
call.
The patient must be located and returned directly to hospital or taken to a place of safety from
where s/he can be returned to hospital as soon as possible. The police may, at their discretion,
undertake a full search of the hospital grounds on larger hospital sites when patients who are
assessed as ‘critical concern’ are reported as missing.
Any patient subject to a restriction order (section 41 or 49) under Part III of the Act is automatically
in the critical concern category if they are absent without leave and the Ministry of Justice must
be informed.
Examples of critical concern
• where a patient is suicidal and there is concern that they have no intention of going home
but are likely to go to a remote location to complete suicide,
• where a patient who has left a health facility is suffering serious mental health issues, is
dangerous, and poses an immediate serious risk to the public’s safety,
• where a patient is suffering from dementia, a learning difficulty, or is lacking capacity, and
there is concern that they will be unable to find their way home safely,
• where a patient is suffering from a serious physical illness or injury and there is concern
that before they arrive home, they may collapse, suffer serious bleeding, or exacerbate an
injury that may result in a permanent disability or long-term medical complications. For
example, a serious head injury, deep wound, compound or complicated fracture, or
overdose.
• The above is not an exhaustive list but are examples of the threshold that would justify
immediately reporting a patient who has left a health setting as a missing person to the
Police with critical concern.
Where there is no critical concern
The patient is detained or liable to be detained under the Act but is considered not to present any
danger to themselves or others. The decision must be made jointly between the ward nursing
team, the CS/NM (or on-call manager if out of hours) and a member of the RC’s medical team or
the on-call junior doctor who may seek advice from the consultant on-call. This category will apply
to detained patients who have received a full assessment and whose mental state, behaviour and
symptoms have improved since admission or are considered to present little or no risk.
The missing patient is not subject to a detention order and does not present any danger to
themselves or others. This decision must be made jointly between the nursing team on duty and /
or the on-call junior doctor or RC (if available).
If there are any significant doubts or disagreements over which category the patient should
be allocated, then the critical concern category should be used.
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3.1.4 Stage 4 – Notification
If, at the completion of stage 2, the patient is not located, the nurse-in charge will notify the
following people and agencies:
The patient’s nearest relative (if detained or liable to be detained) must be informed immediately
that the patient is known to be absent without leave. A telephone call may be the most appropriate
method of contact, but alternatives should be recorded if preferred by the nearest relative. There
may be times when it is impractical to notify the nearest relative immediately, but all efforts must be
made to inform them within one hour after the patient’s absence is known and documented.
Sharing information with the nearest relative should only happen where we have a record that the
AWOL patient has consented to them being kept informed of any care changes etc. The exception
to this is where there is a risk to the nearest relative. See code of practice 4.31 to 4.36 CoP.
For informal patients, the next of kin and / or a friend / carer / relative previously identified by the
patient should be notified immediately unless there are sound reasons for not doing so. An
example where it may not be appropriate to notify the next of kin or others is where a voluntary
patient has expressly stated that they do not want their relatives to know their whereabouts and
there are no assessed risks.
If there are child protection / victim protection issues, then the appropriate agencies need to be
informed.
Other persons or agencies that may need to be informed of the patient’s absence are detailed in
Table 1 below:
Remember that a missing patient’s Risk Category can alter whilst the patient is absent
without leave or missing and that all agencies must be informed of any decision to alter
their Risk Category.
3.2 Detained Patient Absconding from Escorted Leave
If a detained patient absconds while on escorted leave, the nurse in charge of the ward must be
immediately informed. Subject to the risk assessment in section 3.3.1, if there is critical concern
the West Midlands police must also be informed.
The patient’s S17 leave must be immediately revoked on RIO /in writing. This will give any
approved social worker, by any officer on the staff of the hospital, by any constable, or by any
person authorised in writing by the managers of the hospital powers to detain the patient under
section 18 MHA.
Staff should make efforts to maintain observations and track the patient’s location.
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It should be decided before leave commences if police will be notified in the event of the patient
absconding.
In order to contact the nurse in charge, the escort must take with them a means of mobile
communication.
TABLE 1: WHEN TO INFORM AGENCIES / INDIVIDUALS
AGENCY
SDM( service
manager)
POLICE
MHA
ADMINISTRATOR
Medical Staff
Switchboard
Operator
Out of Hours:
CNMs/CSMs(nurse
manager /service
manager)
(via Senior Duty Nurse)
Nearest Relative / Next
of Kin
Local Authority
For ALL categories of risk, the following people should be
informed within the given timescale
Immediately
Immediately, if there is critical concern i.e. a need to inform police
Immediately
Office Hours: RC or Consultant ASAP
Out of Hours: On-call Junior Doctor Immediately
Immediately (0121 301 0000)
CNMs/CSMs
discretion as to when on-call Duty Manager
is informed
Within 1 Hour of patient missing, if permission exist to inform them
If involved, inform by 09:00hrs
the following day working day
Care Co-ordinator
Care Quality
Commission
Ministry of Justice
Within 24 hours
As soon as a detained patient is AWOL from a Low, Medium or High
Secure hospital.
When restricted patients go AWOL and when they return
3.3 Returning an AWOL Patient
Section 18 of the Mental Health Act provides powers for the return of patients who are absent
without leave and liable to be detained in hospital. The patient may be taken into custody and
returned to hospital by an Approved Mental Health Professional (AMHP); any officer on the staff of
the hospital; any police officer; or any person authorised in writing by the hospital managers. More
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than one agency may be involved in returning the patient, so cooperation between agencies is
vital.
If the police locate an AWOL patient, they may either return the patient to hospital or inform the
appropriate Trust manager of the patient’s whereabouts. Section 6 of this policy details the
procedures for returning missing patients when they are located.
The National Police Chief’s Council. Advice to Police Forces on the Interpretation of the Multi-
agency Response for Adults Missing from Health and Care Settings Framework id found in
appendix D.
When a patient who is liable to be detained, is located outside of the West Midlands, the CNM or
on-call manager if out of hours, is delegated to act on behalf of the Hospital Managers to authorise
the detention of the patient at a local hospital in writing. Such authority can be provided by fax. The
manager should also ensure that the relevant clinical details are provided to the host hospital.
3.4 Return of AWOL Patients
The detaining hospital has primary responsibility for returning AWOL patients to their place of
detention.
Where healthcare staff seek police support in their attendance to return an AWOL patient, this can
be offered by police where a patient is likely to be ‘violent or dangerous’ in order that officers can
prevent a breach of the peace. Agreeing to joint attendance against this threshold is perfectly
permissible and often necessary to prevent serious risks to healthcare staff.
When the missing patient is located, the CNM or on-call manager, as appropriate, is responsible
for taking the decisions as to what staff and resources are to be utilised in organising the return of
the patient. See Box 2 below.
Example
A missing patient is located after normal hours and a member of the ward nursing team
has a positive relationship with the patient. The only community team available to assist
may be the Home Treatment Team. It would be appropriate in these circumstances for the
manager to deploy a member of the HTT to the ward to cover the duties of the ward-based
nurse to facilitate the involvement of the ward-based nurse as part of the team sent to
persuade the patient to return.
The manager responsible may request police assistance only if they think this is necessary.
The manager responsible for organising the return of the patient will make a decision as to the
mode of transport used as well as the number and skill mix of staff required to ensure the patient’s
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safe return. In circumstance where police assist, it will be highly unlikely that they would return a
patient in a police vehicle.
Where a detained patient is taken to another hospital, the CS/NM (clinical service manager , nurse
manager ) may make arrangements for the return of the patient or delegate responsibility for
organising the patient’s return to the nurse in charge of the ward. The person organising the return
should ensure that the appropriate transport and escorts are organised to collect the patient,
usually within 36 hours of receiving notification of their whereabouts.
Where a patient who is liable to be detained is believed to be on premises to which access has
been refused, then an officer of the hospital can be authorised by the CNM to apply to a magistrate
for a warrant under section 135(2). The warrant will authorise any police constable to enter the
premises, if need be by force, and remove the patient. West Midlands Police will expect NHS staff
who can take ownership of the detainee’s care to be present when executing a warrant under
s135(2).
The Clerk to the Magistrates Court has agreed a “fast-track” procedure for the application of a
warrant under section 135(2), and this is attached as Appendix E of this policy. Section 135(2)
warrant would be normally secured by NHS staff (Social worker in secure care, and social worker/
care coordinator / CS/NM in other settings.
Where a patient who is AWOL is taken into custody or returns after 28 days, within the first week,
the RC must examine the patient and if the relevant conditions are satisfied complete; Form H6,
renewal of authority to detain or CTO8 for CTO patients or form G10 for guardianship patients. If
this authority to detain isn’t completed within one week, the detention / guardianship will lapse, and
the patient will automatically become informal.
If the patient remains AWOL past midnight on the first day of AWOL and is detained / or liable to
be detained, the Nurse in Charge must inform the Care Quality Commission using the reporting
form found on the Trust Intranet on the MHA page. This practice ensures the most up to date
version of the form is being used.
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3.5 Time Limits
Patients who are absent without leave and on Section 3, 7, 37 (both hospital order and
guardianship order) 47 or a recalled community treatment order can be returned:
Up to six months after going absent without leave.
Or
Until the expiry date of the section they are under
Patients on restricted Sections 37/41, 47/49 and 48/49 are not subject to time limits and can be
retaken for as long as their section is in force.
Should a patient remain absent for a prolonged period, regular clinical reviews of the patient’s
absence and risk must be completed and documented.
For patients identified as High Risk/critical concern, a daily appraisal of the information and
circumstances must be undertaken.
For those patients who are assessed as a Medium Risk, reviews should be arranged twice each
week for the period of the patient’s absence.
For Low-Risk patients, such reviews should occur as agreed by the team involved, but should be
undertaken at least every two weeks.
The reviews indicated above should involve, as a minimum:
• The RC for the patient
• The nurse in charge of the ward or community team responsible for the patient’s care
whilst on leave.
• A CS/NM.
• A representative from the police should be invited if there is sufficient concern over the
•
patient’s absence.
In the event a police representative is unable to attend, CSM to make contact with
relevant lead in WMP for update and ensure risk status of missing patient is agreed
between mental health services and police. If there is a change in risk status by police,
which is not agreed by the mental health team, this can be challenged via the
escalation route with WMP (annex K)
These reviews will be to consider the current risk status of the patient, review all actions taken to
locate the patient and to agree any further actions that may be appropriate. This may include press
involvement for which detailed guidance is found in the Patient safety policy. In general, however,
all press contact should be channelled through the Trust’s Director of Communication on 0121 301
1296 or in their absence the Media & Communications Manager or member of the
Communications team on 0121 301 1298, who will be responsible for liaison with the media and
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communication with the Chief Executive Office. No member of staff should speak to the press
unless the above channels of communication have been followed.
3.6 Missing Community Patients
When a member of a Community MDT becomes aware that a patient is missing from their normal
residence the following actions should be considered and documented accordingly on RIO
An MDT meeting or discussion should be held as soon as reasonably possible and include the
Team Manager and Consultant or their deputies.
The risks to the patient or others should be assessed by thorough review of RIO documentation
including clinic letters, progress notes, care plans, advance statements and risk assessments with
particular attention paid to any recent communication from the missing patient.
Assessment of this risk should take into consideration any recent adverse events, significant
anniversaries, community disruption (such as neighbour disputes, gang activity etc.)
For patients considered to be at critical concern the police should be contacted. This needs to be
reviewed on an ongoing basis as the risk may increase in line with the duration of being missing.
Where there is a registered carer or a next of kin recorded on RIO contact should be made with
them to assist with locating the individual. Where the MDT feel, this may lead to a breach of
confidence the decision to do so must be subject to MDT discussion and documented accordingly.
In similar fashion the MDT must consider contacting known friends, associates, ex-partners and
wider family members after due consideration of confidentiality issues.
Repeated efforts should be made to visit the patient’s normal residence and “calling cards” with a
polite and clear message asking the individual to contact his community team should be left on
each occasion.
The individual should be telephoned (or video called, or texted, or e-mailed or any combination
thereof) asking them to contact the community team. A more formal letter may also be posted or
left at the residence.
Contact should be made with other agencies involved in the individual’s care – this may include the
GP, social care, employment support agencies, advocates etc. When contacting any of these the
last known contact should be elicited together with a view (if possible) on the individual’s mental
state or general demeanour. Last known collection of prescriptions from GPs and dispensation
from relevant chemist should be determined.
Discreet enquiries may be made with neighbours without disclosing the nature of the team’s
involvement.
The community team should consider asking the HT team to visit on an out of hours basis.
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In the event of successfully locating the individual then consideration should be made to amending
care plans, contact details, risk assessments and alerts on RIO to reflect the possibility of repeated
events in future and to guide the MDT response.
3.7
Recording
Every step of the procedure must be fully documented and relevant documents completed within
the patient’s care record and copies of all forms kept for the records.
All incidents of AWOL must be recorded on ECLIPSE (the Trust electronic Incident Reporting
System).
4 Responsibilities
This should summarise defined responsibilities relevant to the policy.
Post(s)
Responsibilities
Ref
All Staff
All staff will ensure Chapter 28 of the MHL Code of Practice (2015) is
adhered to in relation to AWOL patients.
The Nurse in Charge / Ward Manager will ensure that the Care Quality
Commission (CQC) is notified of any detained patient AWOL from a
secure environment)
The Nurse in Charge / Ward Manager will manage the AWOL situation
using the checklist in Appendices.
The Nurse Manager (CNM) or On-Call Manager (out of Hours) will provide
support and assistance where appropriate.
All AWOL incidents will be recorded on ECLIPSE (the Trust Incident
Recording System)
Nurse in
Charge
Responsibilities
The nurse in charge of the ward is responsible for ensuring that all
required agencies and persons are informed within the relevant time
scales.
This is to be recorded on the AWOL checklist (Appendix F)
Clinical
Service
Manager
For High-Risk category patients, the CSM’s responsibility is to co-ordinate
the attempts to locate the patient immediately. It is the manager’s
responsibility to notify and determine the level of involvement of the Home
Treatment Team. Any delegation of responsibility should occur after the
following information has been considered:
• The circumstances under which the absence has occurred.
•
If the patient has failed to return or is recalled from s.17 leave; the
length of the authorised leave and any progress reports received
during the leave.
• The care plan agreed for the leave, and any conditions attached to
•
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the leave granted.
If the patient is on CTO, what conditions are attached?
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• Risk posed by the patient.
•
•
Is there an appointed care co-ordinator that knows the patient?
Is there a member of staff with whom the patient has a positive
therapeutic relationship?
• Any previous episodes of periods of absence without leave?
• Any addresses, places or areas where the patient may have been
located or has attended previously.
• What staff are available, including ward and community-based
staff.
• Organise appraisal meetings to review the information and
circumstances. The frequency of these will depend on the degree
of risk.
• Ensure all relevant parties are invited to the meetings e.g. police to
the appraisal meetings.
• Annual audit of
• Monitor compliance with the police as set out in section 9.
• Review the policy as and when required, but at least every 3 years
and when issues relating to missing persons arise in lessons learnt,
change of regulations or national policy.
• Act as a subject matter expert in relation to missing persons.
• Ensure the policy is ratified in accordance with trust Procedures.
• Ensure the Policy is reviewed at appropriate intervals
Policy
Lead
Executive
Director
Others…
5 Development and Consultation process
Consultation summary
Date policy issued for consultation
Number of versions produced for consultation
may August 2024
3
Committees / meetings where policy formally
discussed
Date(s)
Where received
West Midlands Police
Summary of feedback
Several comments were
received regarding clarity of
police actions
Actions / Response
Comments were incorporated
into the policy. The latest police
procedures on missing persons
has been added to the policy as
appendix .
6 Reference documents
• Mental Health Act
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• Mental Health Act Code of Practice.
• West Midlands Police Missing Persons Procedures.
• Mental Capacity Act
• Confidentiality Policy
• Right care Right person national partnership agreement
https://www.gov.uk/government/publications/national-partnership-agreement-right-
care-right-person/national-partnership-agreement-right-care-right-person-rcrp
• Right care right person national college of policing tool kit
https://www.bing.com/search?q=right+care+right+person+college+of+policing&cvid
=1fa65524cd014126849058eeb9274298&gs_lcrp=EgZjaHJvbWUqBggAEAAYQDIGCA
AQABhAMgYIARBFGDkyBggCEAAYQDIGCAMQABhAMgYIBBAAGEAyBggFEAAYQ
DIGCAYQABhAMgYIBxAAGEAyBggIEAAYQDIICAkQ6QcY_FXSAQkxNzYxMWowajG
oAgCwAgE&FORM=ANAB01&PC=U531
• Right care Right person National police chiefs council advice
https://www.npcc.police.uk/SysSiteAssets/media/downloads/publications/publication
s-log/national-crime-coordination-committee/2023/npcc-advice-requesting-missing-
person-enquiries-in-another-force-and-transfers-of-investigations.pdf
• Right Care, Right Person position statement - March 2024 | Independent Office for Police
Conduct (IOPC)
• The multi-agency response for adults missing from health and care settings (npcc.police.uk)
7 Bibliography:
• Care Records Policy
• Clinical Risk Assessment Policy
• Transporting Patients Policy
8 Glossary
Absence With Out Leave (AWOL)
Patients detained under Part 2 of the Act and Sections 37, 47 or 48 are absent without leave if
they:
• Are absent from the ward without authority granted under section 17; or
• Fail to return from leave at the specified date and time; or
• Are absent without permission from the address where they are required to live by the
conditions of their leave.
• Patients detained under Part 3 of the Act (excluding s47 & 48) are absent without leave if
they:
• Are absent from the ward without authority granted by the remanding court -sections 35 &
36.
It should be noted Patients absent under S38 can only be arrested by police and returned to the
court which made the order/remand.
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• Fail to return from leave in accordance with Ministry of Justice directions - Sections 37 / 41;
47 / 49; and 48 / 49.
• Are absent without permission of the Ministry of Justice, from the address where they are
specifically required to live as part of their Conditional Discharge – section 41.
CTO patients are absent without leave if they:
• Fail to attend hospital when they are recalled.
• Abscond from hospital after being recalled there.
Guardianship patients are absent without leave if they:
• Are absent without permission from the place where they are required to live by their
guardian.
Detained Patients
Detained patients are those who are subject to lawful detention under the Mental Health Act, 1983.
Patients who are liable to be detained
People under this category are those who are subject to detention by virtue of an application made
under Part II of the Act, or by order or direction under Part III and Hospital Managers have yet to
receive the detention papers.
Restricted Patients
An offender can become a restricted patient by a number of routes and may be diverted from the
criminal justice system to hospital for treatment by a court under the Mental Health Act 1983. The
routes:
1. The court issues a Hospital Order (s37) with restrictions added under s41 (including those
found unfit to plead and not guilty by reason of insanity).
2. An offender can be subsequently transferred to hospital from prison by the Secretary of
State (s47) convicted prisoners with restrictions added under s49.
3. An offender can be subsequently transferred to hospital from prison by the Secretary of
State (s48): remand and unsentenced prisoners, Immigration Detainees and Civil Prisoners
transferred to hospital with restrictions added under s49.
4. Hospital directions (s45A/45B): patients with a parallel prison sentence who will be sent to
prison if treatment in hospital is successful.
Critical concern
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Where there is critical concern for the patient’s or the public’s safety that creates an Article 2 or
Article 3 ECHR duty and requires an immediate police response include:
• where a patient is suicidal and there is concern that they have no intention of going home
but are likely to go to a remote location to complete suicide,
• where a patient who has left a health facility is suffering serious mental health issues, is
dangerous, and poses an immediate serious risk to the public’s safety,
• where a patient is suffering from dementia, a learning difficulty, or is lacking capacity, and
there is concern that they will be unable to find their way home safely,
• where a patient is suffering from a serious physical illness or injury and there is concern
that before they arrive home, they may collapse, suffer serious bleeding, or exacerbate an
injury that may result in a permanent disability or long-term medical complications. For
example, a serious head injury, deep wound, compound or complicated fracture, or
overdose.
The above is not an exhaustive list but are examples of the threshold that would justify immediately
reporting a patient who has left a health setting as a missing person.
Considerations therefore include whether there is concern that:
• does not intend to go home and may complete suicide or cause serious self-harm,
•
•
•
the person is dangerous,
the person will be unable to make their way home safely, or
the patient needs urgent treatment in the next few hours otherwise they may suffer life
changing or life limiting injuries and they were either not aware of that when they made the
decision to leave or the patient lacks capacity and is unable to understand the
consequences of leaving.
Police Response if there is Critical Concern
1)
(a)
(b)
(c)
Where a patient who is for the time being liable to be detained under this Part of this Act in
a hospital —
Absents himself from the hospital without leave granted under section 17 above; or
Fails to return to the hospital on any occasion on which, or at the expiration of any period
for which, leave of absence was granted to him under that section, or upon being recalled
under that section; or
Absents himself without permission from any place where he is required to reside in
accordance with conditions imposed on the grant of leave of absence under that section, he
may, subject to the provisions of this section, be taken into custody and returned to the
hospital or place by any approved social worker, by any officer on the staff of the hospital,
by any constable, or by any person authorised in writing by the managers of the hospital.
If the level of risk does not justify immediate police deployment, it is unlikely that the threshold of
critical concern will have been met, and police forces are entitled to expect the health agency to
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conduct reasonable actions to locate the patient, including checking the home address, before the
police will respond.
However, even when there is an Article 2 or Article 3 ECHR duty, the framework recommends a
partnership response to these emergency incidents. On many occasions in the past, the police
have voluntarily assumed complete responsibility to locate missing patients despite Health,
Ambulance, and Mental Health having the same Article 2 or Article 3 duty, as those duties apply to
all statutory agencies.
Where more than one statutory agency is involved, the question is, which agency should be the
lead agency? When a patient leaves a medical facility, if they are suffering a medical or mental
health crisis, health or mental health should be the lead agency it is in the best interests of the
patient if:
• a BSMHFT member of staff /mental health professional checks the home address if the
person is suffering from mental health issues.
This is in recognition of the principle of deploying the most appropriate resource to the home
address. Ambulance staff and mental health professionals have more relevant skills, training, and
experience than the police to treat and advise the missing patient if the patient has managed to
find their way home.
The police are better focussing on the co-ordination of area searches, mobile phone checks, and
ANPR checks to locate the patient if the patient has not gone home.
it is not in the best interests of the missing patient for a police officer to attend the patient’s home
address on behalf of health agencies in order to persuade the patient to return to a hospital,
surgery or clinic for treatment. If police officers do attend, they must rely on persuasion as the
police have no powers to force a patient to return for treatment even if that treatment is considered
life-saving and essential.
Police officers are not trained to explain the health consequences of not receiving treatment and
should avoid attempting to do so as they may create legal liabilities. If the patient is suffering a
mental health crisis, it can also exacerbate their condition if a uniformed police officer attends their
home.
Police forces may therefore decide it is in the best interests of the patient to request an ambulance,
health professionals, or mental health professionals to conduct the welfare check at the home
address whilst they conduct area searches and other specialist enquiries.
If BSMHFT staff unable to check the home address due to the risk of harm posed by the missing
person to BSMHFT staff being assessed as significant and this is not manageable without police
support.
This should be conveyed to the police (via recorded 101 or 999 call) and recorded on rio
If there is an Article 2 or Article 3 ECHR duty and when the health agency refuses to deploy a
mental health professional, the police should not also refuse to attend, as the failures of other
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agencies does not absolve the police from their own Article 2 and Article 3 duties even if health
agency is the lead agency and the most appropriate resource to respond.
If the Home Address is Unknown or the Patient is No Fixed Abode
If the home address of the patient is unknown or the patient is no fixed abode, then consideration
should be given to whether the patient had capacity, was aware of their medical condition, was
aware of the consequences of not receiving treatment and has made an informed decision to leave
a health facility prior to treatment. An adult with capacity is entitled to refuse treatment even if they
consequently suffer death or serious injury. If the health care setting has reported the patient
missing to the police, the police should discuss that risk assessment with the health care setting to
decide whether it is more appropriate to consider the patient as a self-discharge.
Police Response if there is No Critical Concern
Where the concern for the patient’s safety is not critical and does not require an immediate police
response, the police are entitled to expect health facilities to conduct reasonable actions to locate
the patient and to establish for themselves whether a missing patient has gone home before
reporting the matter to the police. Even if the staff at the health facility cannot themselves
physically check the home address, the health facility is responsible for considering alternative
ways of doing so. For example, the health facility may consider requesting a relative, friend,
ambulance, the community health team, or the mental health team to check the home address on
their behalf. Police forces may wish to ensure their local protocols address this issue.
Traditionally, police officers have felt obliged to take responsibility where health are struggling to
deploy resources to the home address. However, if there is no critical concern that justifies an
emergency police response, police forces may decide not to respond and allow the health facility to
resolve the issue in their own time. The police do not owe a duty of care under the common law to
conduct welfare checks on behalf of other agencies unless the police create a legal duty of care by
agreeing to complete that welfare check. In those cases where the police decide not to complete
the welfare check, the police will make it clear to the reporting person that the police will not be
responding so that no legal duty of care is created.
If there is a delay in the home address being checked by health, this is acceptable as the risk
assessment has indicated that there is no critical concern that justifies an emergency response.
The police do not need to be informed about these incidents where the health facility has not
conducted reasonable actions to locate the patient and there is no critical concern.
If the Health Agency has Conducted Reasonable Enquiries.
If the health agency recontacts the police after conducting reasonable actions to locate the missing
patient and confirms that the home address has now been checked, and the patient has not
returned home as expected, and is therefore also missing from their home address, police forces
may then decide to categorise the patient as a missing person if there are any suspicious or
concerning circumstances. The police would then conduct a risk assessment and categorise the
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risk as high, medium, low, or very low risk in accordance with their ‘Missing Person policies’ and
respond in the same way that they would do to any other report of a person missing from home.
Audit and assurance
9 MONITORING TOOL – MISSING PATIENT POLICY
Lead
Tool
Frequency Reporting Acting on
Matron Missing
Patient
Audit
Quarterly CGC
Recommendations
and Lead(S)
Recommendations
to be prescribed by
nominated
members of and
received by CGC
Change in
Practice and
Lessons to
be shared
As
determined
by the CGC
Matron Missing
Patient
Audit
Annual
CGC
Recommendations
to be prescribed by
nominated
members of and
received by CGC
As
determined
by the CGC
Elements to be
monitored
1A Has an
incident form
been completed
on ECLIPSE for
every patient
who has been
AWOL?
(3.9.2)
1B Missing
patient form B
(appendix B)
and C(
appendix c) is
completed
when a patient
absents
themselves
from an
inpatient setting
(3.9.1)
10 Appendices
APPENDIX A
MISSING PATIENT MONITORING FORM
APPENDIX B
MISSING PATIENT FORM 2
APPENDIX C
RISK RATING
APPENDIX D
POLICE PROCEDURE
APPENDIX E
OBTAINING A WARRANT, s135
APPENDIX F
AWOL CHECKLIST FOR NURSE IN CHARGE
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APPENDIX G
APPENDIX H
NOTIFICATION OF ESCAPE/ABSCOND AND RETURN OF A
RESTRICTED PATIENT
PREVENTION OF PATIENTS MISSING FROM HEALTH CARE SETTING
APPENDIX I
MISSING PERSON FROM HEALTH CARE SETTING
APPENDIX J
MISSING PERSON WHEN FOUND
APPENDIX L
EQUALITY MONITORING FORM
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Appendix A
NAME
……………………………………………
Age
………………………
PART 1: PATIENT REPORTED MISSING
WARD / UNIT ……………………………………………
MHA Section ………………………
……………………………………………
Date Missing ………………………
PATIENT ID NO……………………………………………
Time Missing ………………………
……………………………………………
Time of Arrest ………………………
RISK CATEGORY: HIGH
MEDIUM
LOW
NOTIFICATION OF PERSON MISSING BY
NAME
……………………………………………
Band
………………………
SIGNED
……………………………………………
Time / Date ………………………
PART 2: PATIENT FOUND AND RETURNED
CIRCUMSTANCES OF RETURN
FOUND BY ………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
………………………………………………………………………………………
……………………………………………………………………………………………………………
NAME
……………………………………………
Band
………………………
SIGNED
……………………………………………
Time / Date ………………………
*Please ensure a copy of this form is sent to the MHA Administrator once Part 1 is complete
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APPENDIX B
MISSING PATIENT FORM 2
NOTIFIED
MISSING
POLICE
DATE /
TIME
BY
WHOM
NOTIFIED
RETURNED
DATE /
TIME
BY
WHOM
POLICE
(Name, Rank & ID)
(Name, Rank & ID)
Confirm that
appendix C has been
emailed or handed
over to police or/and
read out during
phone call in full
RC
CSN/M
Switchboard
Operator
Relative / Carer
AMHP
GP
RC
CSN/M
Switchboard
Operator
Relative / Carer
AMHP
GP
Care Co-ordinator
Care Co-ordinator
MHA Administrator
MHA Administrator
Missing patient form
1 sent
CQC
(If AWOL from a
secure environment)
CQC
(If AWOL from a
secure environment)
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–
–
ONE COPY TO SDM AND ONE COPY TO MHA ADMINISTRATOR:
WHEN COMPLETED
SECOND COPY TO SDM AND ONE COPY TO MHA ADMINISTRATOR:
WHEN COMPLETED AND PATIENT RETURNED
APPENDIX C
RISK RATING informed by Trust Approved Risk Assessment Tool (level1 or HCR20)
(circle appropriate answer and give narrative as appropriate )
To be completed by Nurse In Charge when police are notified of missing patient.
A copy to be handed to Police Officer attending/ emailed to police /or read out during call to police ; a copy to patient’s
records and to the MHA Administrator
Risk Factor
Detention under the Mental Health Act
1983
Voluntary or Informal Admission
Suggest
critical
concern
Set out Why
is this risk
considered
to be present
An application has
is being,
been, or
completed. Patient is
presenting a risk to
themselves or others.
Patient IS presenting
a risk to themselves
or others.
mental
illness such as
Features of
psychosis , sever depression , mania
hypomania
Yes
Substance misuse?
Dependant on
drugs or substances
illicit
Alcohol misuse?
Alcohol dependent
Suspected imminent risk of suicide or self
harm?
Yes
Involved in a violent and / or racial incident
immediately prior to assessment?
Yes - serious incident
Out of character; e.g. unusual behaviour
prior to assessment; disappeared with no
prior indication etc.
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Yes
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Family / relationship problems or recent
history of family conflict or abuse
Recent or ongoing victim of bullying or
harassment trauma ; e.g. racial, sexual etc.
Non-compliance with medication
Yes
Yes
Yes
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Appendix D
Advice to Police Forces on the
Interpretation of the Multi-agency
Response for Adults Missing from
Health and Care Settings Framework
Introduction
The Multi-agency Response for Adults Missing from Health and Care Settings Framework was
commissioned by the All-Party Parliamentary Group for Runaway and Missing Children and Adults
and developed in consultation with a dedicated Task and Finish Group.
The framework provides a basis for multi-agency protocols for the strategic and operational
response to adults who leave health and care settings including residential care homes. It seeks to
ensure that the right care is provided by the right person in the best interests of patients and
residents.
The framework can be accessed by clicking on the below link:
Policy paper overview: The multi-agency response for adults missing from health and care settings:
A national framework for England - GOV.UK (www.gov.uk)
This supporting advice has been written to assist police forces to interpret the Multi-agency
Response for Adults Missing from Health and Care Settings Framework in accordance with the
intentions of the Task and Finish Group who developed the framework.
The NPCC Lead for Missing People is grateful to health and social care colleagues for
acknowledging that the response to missing patients and residents from health and care settings
requires a multiagency response and there should not be an over reliance on police resources.
The framework recommends that health and care professionals should make initial enquiries to
ascertain the whereabouts of the missing patient or resident before contacting the police unless there
is ‘critical concern’ for someone’s safety. Police forces may wish to interpret the term ‘critical
concern’ in accordance with their legal duties as:
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•
a real, immediate risk of death or serious harm that creates an Article 2 ECHR duty and
justifies an immediate police response,
• a ‘real and immediate risk of cruel, degrading or inhuman treatment, and/or a prolonged
period of pain or distress that creates an Article 3 ECHR duty that justifies an immediate
police response,
•
there are suspicious circumstances that indicate that the person may have been a victim of a
serious crime.
The framework is intended to lead to a more consistent approach to missing from health and care
settings throughout England.
This framework is currently England specific as the Task and Finish Group, as set-up, was not able
to consider the different statutory pictures in Wales, Scotland, and Northern Ireland. However, it is
felt that there is potential to extend the application of this framework to Wales, Scotland, and
Northern Ireland, perhaps with local-specific amendments, if their national statutory organisations
and bodies desire to do so.
Application of the Framework
The Missing Adults Framework only applies to adults who go missing from health and care
settings, not to adults who go missing from their private or family home.
It therefore applies to:
1) Adult patients who go missing from temporary locations that they are visiting for treatment such
as:
a) Acute Hospitals,
b) Doctor’s Surgeries,
c) Medical Clinics.
2) Adult patients who have either been detained under the Mental Health Act, or are voluntary
patients, who have been admitted to a mental health hospital for treatment.
3) Adults with care and support needs who are living in a residential care home providing care and
accommodation such as:
a) residential care homes for the elderly; and
b) residential care homes for people with disabilities or learning needs.
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Section 1 - Acute Hospitals, Doctor’s Surgeries and Medical Clinics
This section applies to patients who go missing from temporary locations that they are visiting for
treatment such as Acute Hospitals, Doctor’s Surgeries and Medical Clinics.
Not all Missing Patients who leave a Health Facility are Missing People
Not all patients who leave a health facility without being formally discharged are missing people.
Many patients go home and consequently their whereabouts can be easily established. A missing
patient is not a missing person if they are at home.
Forces may therefore wish to agree with partner agencies when they should report a patient who
leaves a health facility without being formally discharged as a missing person to the police. For
example, police forces may decide with their partner agencies that when a patient has left a hospital,
doctor’s surgery, or medical clinic:
1) the patient will be immediately categorised as a missing person where there is critical concern
for the patient’s or public’s safety that justifies an immediate police response (i.e., an Article 2
or Article 3 duty, or there are suspicious circumstances that suggest the patient may have been a
victim of a serious crime);
2) the patient will not be categorised as a missing person where there is no critical concern for the
patient’s or the public’s safety unless the health agency has conducted reasonable actions to locate
the patient, including checking the patient’s home address, and the patient is now considered to
be missing from home, as well as missing from the medical facility.
If there is critical concern that justifies an immediate police response, the police would normally
record the patient as a missing person and conduct enquiries to locate the missing patient.
If there is no critical concern that justifies an immediate police response and the health agency has
not conducted reasonable actions to locate the patient, including checking the home address, the
police may decide to advise the health agency to conduct those reasonable actions, including
checking the home address, and close the incident log as ‘other agency dealing’ without recording
the patient as a missing person.
Examples of Critical Concern
Examples of where there is critical concern for the patient’s or the public’s safety that creates an
Article 2 or Article 3 ECHR duty and requires an immediate police response include:
• where a patient is suicidal and there is concern that they have no intention of going home
but are likely to go to a remote location to complete suicide,
• where a patient who has left a health facility is suffering serious mental health issues, is
dangerous, and poses an immediate serious risk to the public’s safety,
• where a patient is suffering from dementia, a learning difficulty, or is lacking capacity, and
there is concern that they will be unable to find their way home safely,
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• where a patient is suffering from a serious physical illness or injury and there is concern
that before they arrive home, they may collapse, suffer serious bleeding, or exacerbate an
injury that may result in a permanent disability or long-term medical complications. For
example, a serious head injury, deep wound, compound or complicated fracture, or
overdose.
The above is not an exhaustive list but are examples of the threshold that would justify immediately
reporting a patient who has left a health setting as a missing person.
Considerations therefore include whether there is concern that:
• does not intend to go home and may complete suicide or cause serious self-harm,
•
•
•
the person is dangerous,
the person will be unable to make their way home safely, or
the patient needs urgent treatment in the next few hours otherwise they may suffer life
changing or life limiting injuries and they were either not aware of that when they made the
decision to leave or the patient lacks capacity and is unable to understand the consequences
of leaving.
Health Conducting a Joint Risk Assessment with Mental Health
In respect of patients suffering from mental health issues who go missing from Acute Hospitals,
Doctor’s Surgeries or Medical Clinics, it is best practice for the medical health professionals to
contact their mental health professional colleagues to conduct a joint risk assessment before
deciding to contact the police. The missing patient may already be known to mental health services
and the mental health professionals will be able to assist the medical health professionals to assess
whether there is critical concern for the missing patient’s or the public’s safety that would justify
contacting the police.
Escalation before Contacting the Police
The Framework also recommends that “the decision to report someone missing to the police should
be agreed with an appropriate (in some cases more senior) member of staff”. The rationale for this
recommendation is that experience has shown that where acute hospitals have introduced an
escalation process to a senior or more experienced member of staff before contacting the police to
make the assessment on whether there is critical concern, this has the biggest impact on reducing
unnecessary reports of missing patients to the police, without having a significant impact on
safeguarding.
Police Response if there is Critical Concern
If there is a real, immediate, substantial risk to life, serious injury, cruel, degrading or inhuman
treatment, that creates an Article 2 or Article 3 ECHR duty, or suspicious circumstances that
indicate the patient may have been the victim of a serious crime, the police must respond
appropriately. Most forces would categorise these patients as high-risk missing persons and deploy
immediately.
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If the level of risk does not justify immediate police deployment, it is unlikely that the threshold of
critical concern will have been met, and police forces are entitled to expect the health agency to
conduct reasonable actions to locate the patient, including checking the home address, before the
police will respond.
However, even when there is an Article 2 or Article 3 ECHR duty, the framework recommends a
partnership response to these emergency incidents. On many occasions in the past, the police have
voluntarily assumed complete responsibility to locate missing patients despite Health, Ambulance,
and Mental Health having the same Article 2 or Article 3 duty, as those duties apply to all statutory
agencies. Where more than one statutory agency is involved, the question is, which agency should
be the lead agency? If there is a serious fire, no one ever questions that the Fire Service should be
the lead agency. However, too often, the police assume primacy in some types of medical or mental
health crises. When a patient leaves a medical facility, if they are suffering a medical or mental
health crisis, health or mental health should be the lead agency. One controversial question is,
which agency should check the home address?
The Task and Finish Group agreed that it is in the best interests of the patient if:
• a medical professional checks the home address if the person is suffering from a medical
condition, and
• a mental health professional checks the home address if the person is suffering from
mental health issues.
This is in recognition of the principle of deploying the most appropriate resource to the home
address.
Ambulance staff and mental health professionals have more relevant skills, training, and experience
than the police to treat and advise the missing patient if the patient has managed to find their way
home.
The police are better focussing on the co-ordination of area searches, mobile phone checks, and
ANPR checks to locate the patient if the patient has not gone home.
The Task and Finish Group acknowledged that it is not in the best interests of the missing patient
for a police officer to attend the patient’s home address on behalf of health agencies in order to
persuade the patient to return to a hospital, surgery or clinic for treatment. If police officers do
attend, they must rely on persuasion as the police have no powers to force a patient to return for
treatment even if that treatment is considered life-saving and essential. Police officers are not
trained to explain the health consequences of not receiving treatment and should avoid attempting to
do so as they may create legal liabilities.
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If the patient is suffering a mental health crisis, it can also exacerbate their condition if a uniformed
police officer attends their home. However, across the UK, there has been a general assumption
that the police should check the home address because of challenges around demands on
ambulances and the unavailability of other health resources. This practice needs to change over
time as we work towards the right care, right person principles.
Police forces may therefore decide it is in the best interests of the patient to request an ambulance,
health professionals, or mental health professionals to conduct the welfare check at the home
address whilst they conduct area searches and other specialist enquiries. In some force areas, an
ambulance is now attending to check the home address in up to 50% of cases. No one expects the
ambulance service to pick up this extra demand overnight, but we should be working as a
partnership towards sending the most appropriate resource on all occasions.
If Health Refuse to Check the Home Address
Some health and mental health trusts are reluctant to deploy an ambulance or mental health
professionals to conduct a welfare check at the home address until the police have attended and
confirmed that the patient has returned home. However, the police have no legal duty to conduct
welfare checks on behalf of other agencies. If a patient has left a health setting, that health agency
not only may have an Article 2 or Article 3 ECHR duty, they also have a legal duty of care that
continues even when the patient has left the health facility. Any health policy that requires the
police to conduct a welfare check at the home address to confirm the patient has returned home
before deploying an ambulance, health professionals, or mental health professionals should be
challenged.
However, where there is an Article 2 or Article 3 ECHR duty and the health agency refuses to
deploy an ambulance, health professional, or mental health professional, the police should not also
refuse to attend, as the failures of other agencies does not absolve the police from their own Article
2 and Article 3 duties even if the other agency is the lead agency and the most appropriate resource
to respond. However, any refusal of the health agency to check the home address should be
escalated and challenged through partnership arrangements as they are the lead agency, and it is not
in the patient’s best interests that police officers are involved when that is not necessary.
In some partnerships, there has been agreement that the fire service will check the home address in
these circumstances. The fire service has greater powers to force entry into premises, although it
should be acknowledged that they are also not health and mental health professionals. However,
how the fire service can assist when health resources are stretched is another issue that local
partnerships may want to consider when developing their local protocols.
If the Home Address is Unknown or the Patient is No Fixed Abode
If the home address of the patient is unknown or the patient is no fixed abode, then consideration
should be given to whether the patient had capacity, was aware of their medical condition, was
aware of the consequences of not receiving treatment and has made an informed decision to leave a
health facility prior to treatment. An adult with capacity is entitled to refuse treatment even if they
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consequently suffer death or serious injury. If the health care setting has reported the patient
missing to the police, the police should discuss that risk assessment with the health care setting to
decide whether it is more appropriate to consider the patient as a self-discharge.
Police Response if there is No Critical Concern
The Task and Finish Group accepted that where the concern for the patient’s safety is not critical
and does not require an immediate police response, the police are entitled to expect health
facilities to conduct reasonable actions to locate the patient and to establish for themselves whether
a missing patient has gone home before reporting the matter to the police. Even if the staff at the
health facility cannot themselves physically check the home address, the health facility is
responsible for considering alternative ways of doing so. For example, the health facility may
consider requesting a relative, friend, ambulance, the community health team, or the mental health
team to check the home address on their behalf. Police forces may wish to ensure their local
protocols address this issue.
Traditionally, police officers have felt obliged to take responsibility where health are struggling to
deploy resources to the home address. However, if there is no critical concern that justifies an
emergency police response, police forces may decide not to respond and allow the health facility to
resolve the issue in their own time. The police do not owe a duty of care under the common law to
conduct welfare checks on behalf of other agencies unless the police create a legal duty of care by
agreeing to complete that welfare check. In those cases where the police decide not to complete the
welfare check, the police should make it clear to the reporting person that the police will not be
responding so that no legal duty of care is created.
If there is a delay in the home address being checked by health, this is acceptable as the risk
assessment has indicated that there is no critical concern that justifies an emergency response.
Ambulance, mental health professionals and other health professionals have their own systems for
prioritising calls for service and it is their responsibility to resolve the issue.
The police do not need to be informed about these incidents where the health facility has not
conducted reasonable actions to locate the patient and there is no critical concern.
If the Health Agency has Conducted Reasonable Enquiries
If the health agency recontacts the police after conducting reasonable actions to locate the missing
patient and confirms that the home address has now been checked, and the patient has not returned
home as expected, and is therefore also missing from their home address, police forces may then
decide to categorise the patient as a missing person if there are any suspicious or concerning
circumstances. The police would then conduct a risk assessment and categorise the risk as high,
medium, low, or very low risk in accordance with their ‘Missing Person policies’ and respond in the
same way that they would do to any other report of a person missing from home.
Section 2 - Mental Health Detained Patients
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This section applies to voluntary patients and patients detained under the Mental Health Act who
have been admitted to a mental health hospital for treatment. Most of these patients will have a
permanent home that they will return to when released from hospital, although some may be
homeless.
Notifying the Police
When a patient from a mental health hospital goes missing, or fails to return from authorised leave
on time, the police are entitled to expect the hospital to conduct reasonable actions to locate the
patient before contacting the police unless there is critical concern. Forces may therefore wish to
agree partnership protocols whereby the hospital does not immediately notify the police of these
incidents unless there is critical concern for the missing patient’s or the public’s safety that requires
an immediate police response.
If there is Critical Concern
The police should always be contacted immediately if there is critical concern for the patient’s or
the public’s safety that requires an immediate police response.
If there is a real, immediate, substantial risk to life, serious injury, cruel, degrading or inhuman
treatment, that creates an Article 2 or Article 3 ECHR duty, the police must respond appropriately.
Most forces would categorise these patients as high-risk missing persons and deploy immediately.
However, forces may wish to seek a partnership response to these emergency incidents and obtain
agreement that hospital staff or mental health professionals will check the home address while the
police conduct area searches, mobile phone checks and other relevant enquiries.
However, if there is critical concern and the hospital staff and mental health professionals are
unable to attend the home address, the police will need to check the home address as there is an
Article 2 or Article 3 duty on all statutory agencies. The failure of one statutory agency to respond,
even if they are the lead agency and the most appropriate resource, will not negate the legal liability
of the other statutory agencies.
If the Concern is Not Critical
Where the concern for someone’s safety is not critical and does not require an immediate police
response, the police do not need to be notified immediately. The hospital staff have a legal duty of
care in these circumstances whereas the police do not.
Forces may therefore wish to consider requiring hospital staff to conduct reasonable actions to
locate the patient, including checking their home address and allowing the patient a reasonable time
to return of their own accord, before reporting the matter to the police.
On some occasions, the hospital may request the assistance of the police to conduct a joint home
address check if there are concerns that the missing patient may be violent. The police may then
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decide to attend to support the hospital or ambulance staff to prevent a breach of the peace and to
assist the hospital or ambulance staff to recover the patient.
If the Missing Patient has not been found by the Hospital Staff
If the hospital staff have undertaken reasonable actions to try and establish the whereabouts of the
missing patient and they have been unable to locate the missing patient, and the circumstances
suggest that the patient is missing from home as well as missing from hospital, police forces may
then wish to apply their ‘Missing Person policies’ when they are contacte
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